CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 685 758.250000 28197.6000 37.1877
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 112 108.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1294 5632.750000 209557.9000 37.2035
Subtotal (Total Children Is Unduplicated) 1338 6499.750000 237755.5000 36.5792
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-COS Exit 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 26 51.000000 3825.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.000000 1350.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 48.000000 2664.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 24.000000 1332.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 342 616.500000 46072.7000 74.7327
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 231 386.500000 28987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 96 169.500000 12712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 182 309.500000 23250.0000 75.1212
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 106 162.500000 12058.1900 74.2042
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 89 161.000000 12075.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 416 724.000000 40265.2500 55.6150
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 370 637.500000 35449.5000 55.6071
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 122 213.000000 15975.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 186.500000 13987.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 4 4.000000 532.4500 133.1125
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 1218 3766.000000 254536.5000 67.5880
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EI Services,Class #03
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 1 0.500000 25.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.500000 25.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 39 34.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 32.000000 1600.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 44 50.000000 750.0000 15.0000
INTR-T1013-INTERPRETER 30 71.000000 3594.0000 50.6197
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 81 124.000000 1488.0000 12.0000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
TRAV-TRAVS-Travel by mile 134 4533.000000 2011.6200 0.4438
Subtotal (Total Children Is Unduplicated) 215 4848.500000 9709.5000 2.0026
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Total 15114.250000 502001.5000 33.2138
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Number of Children (Unduplicated) With at Least One Service 1541
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 39 210.000000 2439.1900 2439.1900
D 5 31.500000 147.2600 0.0000
S 0 0.000000 0.0000 0.0000
H 137 193.000000 13373.2500 7917.7500
T 15 44.500000 1298.9000 1298.9000
27 34.250000 2300.8500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 223 513.250000 19559.4500 11655.8400
Center 02
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 53 1456.000000 2781.6900 2781.6900
0 0.000000 0.0000 0.0000
Other 203 251.250000 5351.3100 0.0000
---------------------------------------------------------
Total 256 1707.250000 8133.0000 2781.6900
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 6 143.000000 310.4100 310.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
202 298.000000 13514.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 208 441.000000 13825.2500 310.4100
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 54 94.250000 3908.5500 0.0000
P 34 56.250000 2270.5500 2270.5500
D 1 1.000000 75.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
168 241.750000 11766.4500 0.0000
Other 1 1.500000 55.8000 0.0000
---------------------------------------------------------
Total 258 394.750000 18076.3500 2270.5500
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 219 203.750000 7579.5000 3645.6000
P 244 2307.000000 12352.6200 12352.6200
D 1 1.000000 37.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
491 374.250000 12071.4000 0.0000
Other 2 1.250000 46.5000 0.0000
---------------------------------------------------------
Total 957 2887.250000 32087.2200 15998.2200
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 5 10.000000 566.0000 566.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.250000 83.7000 0.0000
520 597.750000 29080.2000 0.0000
Other 7 8.250000 306.9000 0.0000
---------------------------------------------------------
Total 533 618.250000 30036.8000 566.0000
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 40 45.000000 2161.8000 0.0000
P 152 249.000000 9131.8900 9119.8900
D 7 14.000000 935.4000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
428 359.750000 14615.8000 0.0000
Other 19 11.500000 453.0000 -12.0000
---------------------------------------------------------
Total 647 681.250000 27408.8900 9107.8900
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 353 668.000000 21789.4400 21789.4400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 264 382.750000 20281.2000 11017.2000
T 0 0.000000 0.0000 0.0000
78 125.750000 8141.1000 0.0000
Other 41 72.000000 4854.0000 0.0000
---------------------------------------------------------
Total 736 1248.500000 55065.7400 32806.6400
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 536 656.000000 31894.2000 0.0000
P 2 12.000000 144.0000 144.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
563 759.500000 38553.7500 0.0000
Other 4 1.500000 55.8000 0.0000
---------------------------------------------------------
Total 1105 1429.000000 70647.7500 144.0000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2 2.000000 138.7500 0.0000
P 15 27.000000 687.0000 687.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8 20.000000 1075.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 26 50.000000 1956.2500 687.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 32 44.000000 2199.6000 65.1000
P 78 117.250000 6155.3600 6077.3500
D 3 6.000000 450.0000 0.0000
S 33 31.500000 1323.0000 30.0000
H 8 15.500000 1162.5000 0.0000
T 48 268.000000 3556.7100 3329.5100
201 235.750000 10752.9000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 403 718.000000 25600.0700 9501.9600
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 33 36.000000 1890.5600 0.0000
P 207 236.000000 11149.3500 11149.3500
D 10 8.750000 352.9500 0.0000
S 25 32.750000 1275.0000 0.0000
H 3 4.500000 337.5000 0.0000
T 6 9.500000 585.7500 585.7500
399 287.750000 11946.4500 0.0000
Other 6 10.500000 691.8000 0.0000
---------------------------------------------------------
Total 689 625.750000 28229.3600 11735.1000
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 5.750000 213.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 81.500000 3595.8000 0.0000
P 430 553.750000 25327.2000 25327.2000
D 13 23.250000 1185.0000 0.0000
S 1 1.500000 112.5000 0.0000
H 2 3.500000 223.5000 0.0000
T 40 137.500000 3273.9300 3273.9300
448 544.750000 23418.0100 0.0000
Other 3 4.750000 249.9000 0.0000
---------------------------------------------------------
Total 1005 1356.250000 57599.7400 28601.1300
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 172 317.250000 16518.6000 0.0000
P 109 202.927467 10469.8400 9628.3400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 15 30.000000 2250.0000 0.0000
T 0 0.000000 0.0000 0.0000
814 905.822533 39548.7400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1110 1456.000000 68787.1800 9628.3400
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 205 374.000000 17862.3000 0.0000
P 5 6.000000 411.0000 411.0000
D 0 0.000000 0.0000 0.0000
S 2 3.500000 233.2500 0.0000
H 20 37.750000 1404.3000 1404.3000
T 0 0.000000 0.0000 0.0000
398 566.500000 25077.6000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 630 987.750000 44988.4500 1815.3000